Microsurgery, a pivotal surgical field that changed medical perspectives in the 20th century, presents numerous technical challenges due to the precision it requires from the surgeon. To acquire the requisite skills, comprehensive training is imperative. Initiation into microsurgical training on experimental models is a prerequisite before translating these skills to clinical applications. The employment of non-living models in medical training offers a myriad of advantages, notably characterized by their accessibility and cost-effectiveness. Non-living models, such as latex gloves, leaves, flower petals, silicon tubes and chicken legs, provide aspiring microsurgeons an opportunity to train the essential technical skills required in microsurgical practice. Such models significantly alleviate ethical concern associated with the use of live specimens and human cadaveric models. Furthermore, they exhibit a satisfactory emulation of human vascular properties, providing a realistic context for medical practice. Although the primary focus of this paper is on non-living models, it is important to highlight the transition to living models, specifically small animal models, as a mandatory and advanced phase in microsurgical training, before translating to clinical practice.

Infections represent the most common complication occurring during the evolution of the severely burned patient, hence requiring closer study and targeted result analysis. The fungal infections are one of the most aggressive types of existing infections, their opportunistic character enabling them to cause invasive infections, ultimately leading to a higher morbidity and a higher rate of mortality. The present study focuses on the presence of Candida spp. in 19 out of a total of 70 patients admitted to the Critical Care Burn Unit in the Clinical Emergency Hospital Bucharest, between 01.01.2019-31.12.2019. No other fungal species, besides Candida spp., were identified in this patient lot. The aim of this study was to analyze the risk factors and the dynamics of the biological parameters of the patients presenting Candida spp. infections, in order to determine how these contribute to the prognostic and final outcome of these patients. We can conclude that a precise diagnostic and prompt treatment can make a significant difference in the outcome of severely burnt patients presenting with a fungal infection.

Facial nerve paralysis is a debilitating condition with multiple etiologies, with aesthetic, functional, psychological and social impact. Given the complex multitude of causes that may generate such condition, a therapeutic algorithm is mandatory when attempting reconstruction. Severity, timing, patient adherence to a rehabilitation program, status of ipsilateral and contralateral facial nerves and particularities of each patient are all criteria which should be accounted when choosing a treatment option. After initial assessment, a variable treatment panel is available based on condition type include medicamentous therapy, rehabilitation program, dynamic and static procedures surgical procedures, having as primary aim functional restoration achieving aesthetic balanced facial features. This paper summarizes current knowledge in facial paralysis reconstruction and presents an algorithmic approach that eases decision making and therapeutic strategy.

Lymphedema represents a chronic condition with impaired lymphatic transport, having primary and secondary etiologies. The most common type of secondary lymphedema in western countries is represented by breast cancer related upper limb lymphedema.
This condition, once installed, determines limb structure changes, progressive functional impairment, specific complications, consequently impacting the quality of patient’s life. An accurate diagnosis is mandatory, using both clinical and imagistic methods with clear definition disease extent as per standardized staging systems, in order to further provide an adequate therapeutic strategy.
The main therapeutic goal in patients with lymphedema is represented by limb volume reduction with subsequent symptoms relief, improving quality of life and avoiding complications such as recurrent infections. Through this paper, we aim to present a comprehensive overview of current therapeutic options of breast cancer upper limb related lymphedema.
Therapeutic approach comprises of non-surgical (conservative) therapy, which is mandatory as initial therapy and surgical procedures for selected cases. Most patients with lymphedema benefit from conservative treatment alone. In non-responsive cases, in patients with progressive disease, in late stage complicated lymphedema, and also recently added as prophylactic strategy, surgical treatment, trough recent developed techniques, offer very good results in long-term control of disease.
Surgical options are classified firstly in physiologic procedures that aim to create new lymphatic channels, promote physiologic drainage of the lymph and should be considered early in the course of the disease, and secondly ablative procedures that reduce through liposuction or various excision techniques the volume of the affected limb.
Both types of techniques can be combined to ensure the best functional outcome of the patient.

Injuries to the upper limb may determine unexpected simple or complex soft tissue defects, due to different types of underlying injury mechanism, clean cut/stabs, crushing, torsion, avulsion or mixed types, which pose a challenge for the reconstructive surgeon. Ideally, all arterial, venous and nervous lesions, in the distal upper limb should be repaired in an end-to-end technique, outside of injury zones, with healthy ends, in a tension free manner. However, situations arise where, either a tension-free repair is not possible, or a considerable defect is met, often representing a challenge to the surgeon. Therefore, a timely decision is imposed in order to find the most favorable approach to restore limb or segment perfusion, ensuring efficient venous return, as well as providing a sensate repair. Usage of vein grafts represents an essential tool comprised in the reconstructive surgeon’s armamentarium, with high versatility in nerve, arterial and venous reconstruction. Not only does it provide an ideal solution, with high adaptability to each case, but it also may enhance short- and long-term outcome, offering an optimal reconstructive option in any upper limb trauma situation, regardless of etiology. We aim to describe our therapeutic strategies in a series of challenging trauma cases involving digital structures from the upper limb. Interposed vein grafts were used to re-stablish sensate function in a patient with a collateral digital nerve defect, but also to bridge vital digit arterial defect in a torsion-avulsion thumb amputation, as well as re-establishing venous flow in patients with Urbaniak II finger degloving injury.

Traumatic dog bite total scalp avulsion is a rare condition. We present a case report on an emergency case, a 52 year old female patient with total scalp avulsion treated in our clinic, with a complex reconstruction using a free microsurgical latissimus dorsi transferred flap.

Severe burn injuries represent a major challenge to the entire healthcare system in developing countries and even for states with a high standard of care. A clear understanding of the physiopathology of burn injuries is essential for providing an adequate prompt treatment to ensure an optimal patient outcome. Early recognition and treatment of burns complications, especially severe infections represent an important prevention strategy, improving survival after these severe injuries. Specific treatment must be conducted according to the characteristics of the patients in order to reduce morbidity and mortality and avoid the development of antimicrobial resistance. A diagnostic and therapeutic algorithm is presented, centered on infectious source prevention and control with early surgical excision and skin grafting together with culture-guided antimicrobial therapy. It is a known fact that, indifferent of the involved germ, the best intervention for both prophylaxis and treatment of infections in the burn patient is the early excision of the devitalized tissue and subsequent closure of burn wounds with skin grafts, measures that diminish local and systemic mediator releasing effects in burnt tissue, attenuating the progressive inflammatory chain.

Due to its complex structure, the abdominal wall is vital as it serves to protect the internal organs, maintain the upright position and regulate the intraabdominal pressure. Complex abdominal defects are a major health problem, with challenging treatment, many complications and risks. It is not a completely elucidated pathology as there is no consensus in literature regarding the definition and classification. Although there are various reconstruction techniques, there is no sistematic protocol in literature that allows the surgeon to choose the best treatment suitable for each patient. Therefore, the first step to manage these patients is a carefull assesment of the patient background and only after that, a complete analysis of the actual wound should be made. Second step is appropriate abdominal wall closure. After the analysis of current data from international literature, we identified a decision-making algorithm to offer guidance in surgical management in order to obtain an optimal functional outcome. The foundation of the algorithm is the idea of gradually improving the local tissue status, in order to deal with a clean wound as much as possible. This way, the success rate of the surgical reconstruction improves.

Infections are the most severe and the most frequent complication in major burns requiring adequate diagnosis and treatment. Extensive burned areas, impaired immune system and antibiotic therapy contribute to the development of opportunistic fungal infections. An important aspect is the increased level of antimicrobial resistance in our country. We present a two years study on the burn patients hospitalized in our institution. A total of 355 burned patients were hospitalized during this period, 210 (59%) of them being addmited in Critical Care Burn Unit. We noted the main infectious complications and established a dinamic microbian mapping during patient hospitalization. Fungal infections were noted. We performed microbiological screening: testing at admission and once a week or in case of clinical signs from all potential sites. For the clinical therapy of mycoses, it is mandatory to know whether a fungal colonization or a fungal infection is involved. Unfortunately, often in severe burned patients, clinical presentation is unspecific and sensitivity of diagnostic results may be unreliable. Invasive fungal infections due to Candida species and Aspergillus species are important emerging causes of morbidity and mortality. The systemic use of antifungal agents is conducted depending on the general condition of the burn patient, the fungal species involved and the confirmation of fungemia. In conclusion, specific treatment of infectious complications has to be conducted according to the characteristics of the patients in order to reduce morbidity and mortality and avoid the development of antimicrobial resistance.

Background: Hydrofluoric acid (HF) is an extremely dangerous weak inorganic acid, which can produce extensive burn lesions, depending especially on the solution concentration and exposure time, systemic toxicity occurring in patients with large burn areas, high concentration of acid or an extensive time of exposure. The subcutaneous infiltration and intravenous administration of calcium gluconate is essential for preventing dyselectrolytemia and severe pain appearance. Case summary: A 26-year-old man patient presented to our hospital after a hydrofluoric burn, secondary to an occupational accident. At the scene, the wound was irrigated with fresh water and topical calcium gluconate was applied. In the Emergency Department, we started the intravenous calcium gluconate administration, and in the Burn Unit it was injected subcutaneously and the pain was thus diminished. A prolonged QT interval was identified upon admission that has been corrected over the next few days. Particularly, the serum pseudocholinesterase levels were within normal range. The local treatment involved repeated copious lavage with sterile water and Betadine solution, the evolution being rapidly favorable with the burn lesions completely healed in the next week. Conclusion: HF burns are a very special type of chemical burn taking into account that exposure to a small quantity of solution can be life threatening and that the immediate treatment is mandatory in order to maximize the outcome. It is of vital importance that any medical facility had a chemical burn protocol.

Introduction: The prevalence of hypokalemia in psychiatric population is very high with eating disorders and laxative abuse being the main incriminated factors. Case presentation: We report a case of a 34-year-old woman with history of sleeve gastrectomy and breast implant, who presented for fatigue, severe myalgia, generalized hypotonia and palpitations. Laboratory exams revealed severe hypokalemia and rhabdomyolysis. The electrocardiography showed prolonged QT interval and ST segment depression with second-degree atrioventricular block. She received intravenous potassium supplementation with consecutive hydration. When potassium level was within safety limits, the patients received loop diuretics in order to decrease rhabdomyolysis and avoid kidney injury. The underlying cause was a pathological behavior, with frequent self-provoked episodes of nausea and vomiting after eating and chronic consumption of laxatives. She started psychotherapy. Conclusion: Psychiatric behaviour can lead to life-threatening conditions, therefore it should be discovered and managed promptly.

High flow nasal cannula (HFNC) oxygen therapy devices are used on a daily-basis in many intensive care units and postoperative wards. Such a device deliver a mixture of air and oxygen, warmed, humidifi ed, with gas flow between 20-60 L/min, and inspired oxygen fraction between 0.21-1. Therefore, it improves oxygenation, decreases dead space, washes out the carbon dioxide (CO2) from patients’ airways, improves thoraco-abdominal synchrony and decreases the work of breathing. Studies have shown effi cacy of HFNC oxygen therapy use for acute hypoxemic respiratory failure, for patients with exacerbations of chronic pulmonary diseases, after extubation in order reduce the need for mechanical ventilation, in perioperative period to prevent atelectasis and in palliative care, in order to reduce breathlessness. It isn`t feasible for patients with severe altered neurological status, facial trauma, basal skull fracture, complete airway obstruction or epistaxis. There are no standardized recommendation for the use or contraindication of HFCN oxygen therapy. The weaning is realised according with patients’ tolerance, oxygen saturation, respiratory and heart rates.

In the last century, the breast reconstruction after mastectomy has become an important element of the multicentric treatment of the patients suffering from breast cancer. Breast reconstruction was initially developed to reduce the complications of mastectomy and the deformations of the thoracic wall. Currently, it is known the fact that reconstruction can improve the psychosocial state and the quality of life of the patients with breast cancer[1]. [...]

Burn injuries are a major public health problem all over the world and despite significant improvements in critical care and surgical treatment, major burns are associated with high morbidity and mortality and poor recovery outcome. Patients with severe burns need immediate intervention and rapid initiation of speci-alized treatment in a dedicated critical care burn unit in order to minimize morbidity and mortality. The complex nature of burn injuries requires an integrative approach, by a multidisciplinary team in order to obta-in an optimal care. [...]

Major burn represents the most severe type of trauma, requiring high standard of treatment into regional specialized bun care centers[1]. According to American Burn Association(ABA), a major burn, which requires hospitalization in burn units, is represented by at least one of the following situations[2,3] [...]

In the last decades, the approach manner of the defects of the soft parts post-mastectomy developed significantly together with the innovative surgical techniques of oncoplastic surgery.
Among these techniques, the reconstruction of the breast with LD flap and implant continues to be a reliable and easy to perform method, both by the experi-enced surgeons and also for the beginners[1]. [...]

It is well known that the thumb is responsible for 40% of the hand function. Th erefore, preserving its length and mobility represents the main objective of the plastic surgeon while choosing the most appropriate reconstruction technique[1]. When resurfacing of the fingers is needed after hand injuries, cross-finger flaps have proved themselves very useful[2]. Since its premier many years ago[3], this type of flap remains an elegant method in order to cover exposed bones or tendons of the fi n-ger, in order to ensure length preservation and function recovery. [...]

Peripheral nerve damage may lead to substantial mor-bidity, and the costs associated with these conditions can be elevated for both the individual and society.
Nerve entrapment syndromes represent a common occurrence, but sometimes are not correctly diagnosed. They appear more frequently and are better known in upper limb. Carpal tunnel syndrome has the higher prevalence, of 3.72% in USA[1]. [...]

Rhinophyma is a benign tumor characterized by a pro-gressive hypertrophy of the nose soft tissues, with a re-ddish and bulky appearance, affecting most frequently elderly Caucasian males[1], which may also cause functional airway obstruction. It is believed to be the end stage of severe acne rosacea, but the real cause and the exact etiology remain unknown[1]. The male to female ratio of rhinophyma patient varies between 5 to 1 and 30 to 1 [2,3]. The diagnosis is based on the clinical features of this rare and disfiguring disease using Rhinophyma Severity Index Score (RHISI)[4]. The main differential diagnosis is the basal cell carcinoma (BCC), with an occult incidence of 3% to 10% in patients with rhinophyma[1]. [...]

The nose represents a common site for skin cancer, especially for Basal Cell Carcinoma (BCC) which is the most common malignant tumor in humans[1-3]. The removal of the tumor will lead to a defect that can involve skin, cartilage and even nasal mucosa. Therefore, reconstruction of this tridimensional structure can be a challenge even for the most experienced surgeons[4]. There are many techniques described in the literature for restoring the lining and skeletal framework[1-8], but all of these techniques should be adapted to the patient’s needs. In this paper we described our preferred surgical method to cover a medium defect of the distal third of the dorsum nasi after tumor excision using a nasolabial flap. In order to perform a single-stage reconstruction, we pushed the limits of the flap measurements and did some tricks so as the pedicle to be well fitted, leading to good aesthetic results. [...]

Postmastectomy radiation therapy decreases the incidence of locoregional disease recurrence in patients with invasive breast cancer and has been proven to reflect a survival advantage for patients with node positive disease[1,2]. The optimal timing and technique of breast reconstruction procedures in patients requiring post-mastectomy radiation therapy are controversial[1] . Patients undergoing postmastectomy breast reconstruction, with a history of prior radiation therapy, present a particular clinical scenario. This is because of their well-documented higher complication rates, secondary to deleterious effects of irradiation on the soft tissue envelope of the remaining breast. [...]

Hand surgery is considered to be the biggest challenge for every plastic surgeon. The social value of the hand is appreciated by any individual, butmostly by plastic surgeons which are, par excellence, hand-working persons. When a hand injury is treated you must consider the Hippocratic concept which states that "healing is a matter of time but it is sometimes also a matter of opportunity". The hand forms a functional unit with the forearm which is a high-precision machine, with multiples levers, who has tactile intelligence that ensure its auto-mechanism, being able to grab and maintain, in any spatial position, large and small tools invented by human genius. The hand is both a motor and sensory organ, and in terms of society,it is an organ of defense, an organ of creation and expression. This is why hand surgery is very important, both in medical and social terms, and any research in this domain has one purpose: improving the treatment of hand injuriesin order to obtain functional results closer to the genetic scale of the divine creation. The purpose of this study was to assess different osteosynthesis techniques in order to establish which one is better in matters of functional results. [...]

Vascularized composite tissue allotransplantation (VCA) is a recent reconstructive entity that bases on the restoration of deformity by the allotransplantation of a vascularised tissue unit with more components (skin, muscle, bone, cartilage, bone marrow, tendon, nerve). Since the field emerged with the first hand transplant performed in France in 1998, VCA showed a huge potential in replacement of extensive tissue defects and disfigurements (after burns, severe high energy trauma like gunshots, congenital facial malformations), offering a viable treatment option for injuries that involve multiple layers of functional tissue, impossible to repair using conventional surgical techniques, permitting restoration of extensive defects in just one stage procedure with good functional and aesthetic results. A significant number of those procedures have been reported worldwide for various anatomic locations including upper and lower extremities, face, tongue, trachea, larynx, abdominal wall, uterus and penis. These procedures are offered for quality of life and functional indications rather than life-saving indications [1-7]. [...]

Compressive neuropathies in the upper limb represent a common and admittedly more and more frequent pathology, given how certain peripheral nerves posess an inherent risk of becoming injured due to anatomical positioning. [14] Obesity rate increase and the ageing of population altogether suggest that compressive neuropathies in the upper limb will become even more frequent in the next decade. [14] Themost common sign of nervous compression is the carpal tunnel syndrome, prevailing in approximately 3% of the general population, followed by the cubital tunnel syndrome, and finally the radial tunnel syndrome, which is quite rare. [9] [...]

Native arteriovenous fistulae (AVF) are the best options for chronic hemodialysis (HD) access. Unfortunately, not every patient fulfils the requirements necessary for this type of vascular access: the artery and the vein implicated in dialysis fistula creation must accomplish some criteria which makes them suitable for this procedure. If these criteria are not fully met, the chances to a successfully intervention and a quick and qualitative maturation of the fistula are dropping [1-5]. An artery that is suitable for AVF creation has an inner diameter > 2 mm, optimal initial flow and elastic walls allowing dilatation to accommodate a supplementary 10 - 20 fold blood flow increase after the AVF is performed [1,2,5-11]. The participating vein must be superficial enough (less than 5 mm from the skin surface), wide enough (a caliber bigger than 2.5 mm) and its walls must allow important dilatation (without fibrosis, injuries, and thickenings). In elderly, diabetics or patients with late initiation of HD some of these demands are frequently absent we need to adapt surgical procedures, taking advantage of any oppor tunity to overcame shortcomings and create a native dialysis access [1,2,5,9].

People have reported themselves differently regarding different species of animals and had different reactions about the animal species. The attention paid to them depends on the role held by them in human life, either as pets or as a method of entertainment, either as research subjects.
Some species enjoy privileges as pets (dogs cats, birds, turtles), others are used to satisfy human native instincts as hunting animals.

Located between the popliteal fossa and the midportion of the calf, centered over de midline raphe, between the medial and lateral heads of the gastrocnemius muscle, the sural flap is the best known neurocutaneous flap of the leg. [1,2]
The sural angiosome was first introduced in practice by Ponten in 1981, when he reported the use of 23 fasciocutaneous proximally based flaps for soft tissue defects.[3] Donski and Fogdestam described the anatomy of the distally based sural flap and presented three clinical cases in 1982. [4]

Basal cell carcinoma (BCC) is known as the most common type of skin cancer with a rapidly rising incidence, 90 % of the cases occurring in the head and neck region. (1) The eyelids are involved in 10% of these cases, making it the most prominent eyelid malignancy. (2) It predominantly affects fair-skin individuals, notably type I and II Fitzpatrick photo types, most of them presenting with a positive history of chronic sunlight exposure. Etiology may be multifactorial, but sun exposure has been involved in most of the cases. (3) Basal cell carcinomas arise from the basal layer of the epidermis, probably as a result of activating the proto-oncogenes and inactivating the suppressor genes in the keratinocytes. (4)

Botulinum neurotoxin has been used in the treatment of various groups of cronic neuromuscular diseases, which include neuromuscular junction signaling, non-neuromuscular transmission, cholinergic, or non-cholinergic.
Having specificity on releasing neurotransmitter vesicles with acetylcholine in the synaptic gap, the main usage of botulinum toxin was as a muscle relaxant drug in painful or painless spastic syndromes.

Malignant peripheral nerve sheath tumors (MPNST) are soft tissue tumors showing neuroectodermal differentiation. They arise in connection to a major nerve trunk, a peripheral nerve or a preexisting neuroma in patients with hereditary neurofibromatosis type 1. [1, 2] They usually develop in the deep soft tissue between anatomic compartments, the root of the limbs (inguinal region, the axilla) being one of the most common sites of occurrence.

The concealment of cutaneous and subcutaneous defects has always been a challenge in surgery. The breast is one of the most important and defining elements of feminine beauty. Neoplastic pathology has always made it difficult to aesthetically repair the extirpated mammary tissue. Plastic and aesthetic surgery and reconstructive microsurgery, through microsurgical techniques of autologous free flap transfers, try to solve these problems.

While the incidence of lip cancers incidence in the central Europe is low 0.7% of all malignant tumors compared to the 1-2% generally considered (2-5), they are extremely important from a clinical and surgical point of view because of the morphological and functional changes involved. More than 90% of these tumours are squamous cell carcinomas (SCCs) and, in lesser numbers, basal-cell tumours (BCCs) however, some adenocarcinomas deriving from the minor salivary glands can be observed and, even more rarely, melanomas, sarcomas and lymphomas. BCCs generally occur in the upper lip and do not usually present lymph node metastases (4, 6). In contrast, SCCs develop most often in the lower lip, with a possibility of neck metastases. Lip carcinomas frequently appear on top of precancerous lesions, such as radiodermitis, chronic chelitis and xeroderma pigmentosum. The diagnosis and treatment of these pre-cancerous lesions, facilitated by a direct view of the lesions, is, therefore, crucially important in order to avoid their evolving into actual tumours. The subjects most at risk of this type of tumour are fair-skinned elderly people who work in the open air. Men are more at risk than women, (1.3% men and 0.3% women) (1) probably because the latter use lipstick or lip-salve (2, 7-9).

The breast has been the expression of beauty and fertility since ancient times. The aesthetic reconstruction of the breast is and has been a challenge for plastic surgeons. Microsurgical techniques of dissection and free transfer are commonly used. During the dissection of one fresh, female cadaver, age 67, a free inferior gluteal flap was taken from gluteal region, using loupe magnification. The dissection preparations were photographed with a high definition camera.

Starting with the first issue, published in 1994, the aim of "Medicina Modern?" Journal has been to promote the significant achievements of the Romanian medical activity, to communicate and share medical knowledge and to be a valuable database of Romanian research. Because the Journal is under the patronage of Bucharest College of Physicians and Romanian Academy of Medical Sciences, doctors and researchers from all Romania and also from abroad can submit their work and most significant results, assuring them of the high standards of morality and ethics of our Journal.